HospitalInspections.org

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Based on interview and document review, the hospital failed to implement its policy to provide care to prevent the sexual victimization between two patients that were engaging in sexually inappropriate behavior on the patient care unit for 2 of 5 patient records reviewed (Patient #1 & Patient #2).

Failure to provide close supervision puts patients at risk for continued victimization.

Findings included:

1. Review of the hospital policy titled, "Precautions Sexual Victimization,"effective 05/19, showed that the nurse was to inform the physician for patients engaging in sexually acting out behavior (touching, kissing) on the patient care unit. The physician would then order line of sight as appropriate to prevent patients from engaging in sexually inappropriate behavior on the patient care unit. The nurse was then to notify the treatment team of any interventions the physician would have ordered for the patient.

Review of the hospital policy titled, "Patient Rights," effective 04/19, showed that patients were to receive care in a safe setting.

2. Patient #1 was admitted on 12/14/19 at 8:48 AM, on an involuntary hold for the treatment of a mental health condition. Review of the medical record showed:

a) On 12/14/19 at 8:48 AM, the patient's physician ordered every 5 minute safety checks for suicide ideations on admission.


b) On 12/14/19 at 11:20 AM, Patient #1 was found under a blanket in Patient #2's bedroom. The patients were kissing and touching each other and were fully clothed.

At 1:45 PM on the same day, Patient #1 and Patient #2 were observed holding hands. Patient #1 invited Patient #2 into her bedroom. It was documented in the nursing notes that Patient #1 was put on line of sight (LOS) and was told to keep a 5 foot distance between her and Patient #2. Review of the every 5 minute patient checks showed the patient remained on every 5 minute checks and was not on LOS. The physician was not notified by the nurse of the concerns about the patient's sexualized behavior.

c) On 12/15/19 at 5:00 PM, Patient #1 and Patient #2 were told on three separate occasions to stop kissing and holding hands. Patient #1 and Patient #2 were then seen walking to Patient #2's bathroom and were told to immediately separate. It was documented in the nursing notes that 1:1 was highly recommended for Patient #1. There was no documentation in the medical record that showed that the physician was notified of the patient behavior or the nurse's recommendation to place the patient on 1:1 observation status.

d) On 12/16/19 at 5:40 AM, it was documented that Patient #1 was found kissing Patient #2. Patient #1 continued on every 5 minute checks. There was no documentation on the patient's every 5 minute check sheet that she was on LOS precautions.

e) The patient observation status was changed from every 5 minutes checks on 12/17/19 at 8:00 AM when Patient #2 was transferred to another patient care unit.

f) On 12/18/19 the patient expressed regret for their previously sexualized behavior towards Patient #2.

3. Patient #2 was admitted on 12/11/19 at 2:49 AM, on an involuntary hold for treatment of a mental health conditon. Review of the medical record showed:

a) On 12/11/19 at 2:49 AM, the patient's physician ordered every 5 minute safety checks for suicidal and assault/homicidal ideations

b) On 12/14/19 at 11:20 AM, Patient #2 was found under a blanket with Patient #1 in Patient #2's bedroom. The patients were kissing and touching each other and were fully clothed.

c) On 12/15/19 at 5:00 PM Patient #2 was found to be touching and kissing Patient #1 on 3 separate occasions. On the same day at 5:30 PM, staff observed Patient #1 and Patient #2 attempting to go into Patient #2's bathroom. Staff redirected the patients. Patient #2 continued on every 5 minute checks.

d) On 12/16/19 at 5:40 AM, Patient #2 was found kissing Patient #1 again.

e) On 12/17/19, Patient #2 was moved to another patient care unit when a bed became available on another unit. The patient continued on every 5 minute checks throughout their sexualized behavior with Patient #1. There was no documentation that the physician was notified of Patient #2's sexualized behavior with Patient #1.

4. On 02/04/20 at 1:00 PM, the investigator interviewed the Director of Intake/Bed Control (Staff #1). Staff #1 stated that Patient #2 was moved to another unit on 12/17/19 when a bed became available on another unit.

Staff #1 stated that anytime patients displayed sexually inappropriate behaviors the nurse should notify the physician so that the most appropriate precautions for patient care could be implemented. The nurse then needed to notify the treatment team about any interventions the physician may order.

5. On 02/04/20 at 4:00 PM, the investigator interviewed the Chief Executive Officer (Staff #2). Staff #2 verified the above information.